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Hypnotic vs. analgesic based sedation - unfair comparisons?
- Steve Benington (5 February 2007)
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Response to 'Sedation in ITU'
- Pradeep Orakkan (14 January 2007)
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Steve Benington, SpR Anaesthesia
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Dear Sir, I read with interest the article by Park et al comparing hypnotic- based sedation (HBS) with analgesia [remifentanil]-based sedation (ABS) in the intensive care unit. Several problems with design of this study prevent fair comparison between the two groups and therefore undermine its conclusions. The authors state that sedation scores were satisfactory (i.e. patients not over-sedated) in a greater proportion of patients in the ABS group. While true of the data provided, this reflects the suboptimal design of the HBS protocol, which makes no mention of sedation holds. Good evidence exists that a daily sedation hold lightens sedation and promotes earlier weaning. If remifentanil is to gain acceptance as the basis of ITU sedation, it must be shown to be superior compared with optimally administered HBS rather than the regimen used here. The authors' assertion that the ABS group weaned faster is based on the fact that this group spent a lesser percentage of total ventilator time in pressure-support mode (PSB) than did the HBS group (9% vs. 22%). This ignores completely the total time spent on the ventilator, nearly twice as long in the ABS group (71h vs. 37h). In fact, the ABS group spent 9% of a much larger time period in PSB mode, hardly less than the HBS group at all. Total time spent in the intensive care unit was also much greater in the ABS group (median stay 118h vs. 67h). While there may be other reasons for this besides the choice of sedation, the authors fail to address this large disparity in their discussion. This is seen despite the fact that encephalopathic patients and those receiving neuromuscular blockers were excluded from the ABS group; such patients might be expected to be sicker therefore requiring a longer stay. While the study was not powered to examine mortality rates, it is interesting to note that no difference was seen between the groups despite this variation in patient selection, which might be expected to favour the ABS group. Remifentanil remains an exciting prospect as a sedative in critical care. However, while the drug used in this study was supplied free of charge by the manufacturer, it is difficult to see the budget of most intensive care units stretching to its widespread use on this evidence. Conflict of Interest:None declared |
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Pradeep Orakkan, Specialist Registrar-ITU The James Cook University Hospital, Marton Road, Middlesbrough, Cleveland, TS4 3BW;
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Editor- I read with interest the article written by Dr.G.Park etal comparing the hypnosis based and analgesia based sedation in the general ITU. Dr.Park was able to prove unto a certain extent that analgesic based sedation [ABS] is better than hypnotic based sedation [HBS]. 63% of the patients receiving remifentanil still needed hypnotics to get a satisfactory level of sedation.This proves that in majority of patients who are only on remifentanil,it is acting only as an adjuant to hypnotics. It is not made clear in the demographics about the characteristics of the group of patients who are managed with remifentanil only. The surgical patients may be in severe pain in the initial postoperative period and hence may need good postoperative analgesia.. This depends on the type of surgery and also it varies with other modes of analgesia like epidural infusion if already administered. In critically ill medical patients pain is usually not a major problem I am trying to find out more about the clinical relevance of this study. I would like to know on the difference on an average the number of days the patients were either HBS or ABS when they are ventilated .It is worth mentioning about the number of ventilator free days in each group. It is also important to find out the incidence of ventilator-associated pneumonia in each group. Finally does it make a difference in mortality or number of days in intensive care? Conflict of Interest:None declared |
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